BILIO-PANCREATIC BYPASS (BPD) AND DUODENAL SWITCH (DS) : 3rd PART
We shall finally describe the results and the future of these operations, that are still uncommon, even if well known among surgeons. For example in France, a recent national survey (2003) has shown that they accounted for less than 1% of all bariatric procedures. In the United States, the rate is slightly increasing, up to 10% (2002). The results in terms of weight-loss are definitely the best in the bariatric field: 85% of long-term excess weight-loss with a success rate of 95% at 2 years*, even in the most severely obese patients. At ten years, there are still 85% of good results.There are dramatic effects on related morbidities as well, such as dyslipidemia and diabetes. Moreover, patients experience less alimentary restraint. The pace of diarrhea slows down over the time to 2-4 a day, whereas the bad smell persists. These operations are delicate and deal with fragile patients; the rate of post-operative complications is higher than in other procedures (5 à 10%) and they are more severe. There is a 1-2% mortality rate. The biggest issues are fistulae or anastomotic leaks, and pulmonary embolism. Nutritional deficiencies are important afterwards (proteins, vitamines and micro-nutrients). A close surveillance including regular blood samples analysis is requested.
The duodenal switch has much in common with the typical bilio-pancreatic bypass, and has the same potential complications; yet it seems that vitamine and protein deficiencies are less important owing to the preservation of the pylorus and the creation of a longer common intestinal channel (1m). In very heavy patients, the North-American surgeon Michel Gagner has successfully suggested a two-steps strategy through the laparoscopic approach, combining the sleeve gastrectomy in the first place, and the duodenal switch as a secondary procedure - or, and this is original, a regular gastric bypass - after 6 to 12 months, before the patients regain some weight**.
* Scopinaro N, Adami GF, Marinari GM et al. Biliopancreatic diversion. World J Surg 1998; 22: 936-946.
** Regan JP, Patterson E, Gagner M. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2000; 10: 514-523.
|
